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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 086804160
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:14:49 PM

Document Has Been Signed on 08/02/2023 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GLEN HAVEN DAY PROGRAMFACILITY NUMBER:
086804160
ADMINISTRATOR:HALL, JACOBFACILITY TYPE:
775
ADDRESS:680 E. WASHINGTON BLVDTELEPHONE:
(707) 954-3113
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY: 30CENSUS: 7DATE:
08/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jacob HallTIME COMPLETED:
03:30 PM
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At approximately 1:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a pre-licensing facility inspection. LPA met with Applicant Jacob Hall and toured the building.
The following items were observed:
-Building was clean and in good repair.
-Fire clearance has been granted.
-Hot water temperature registered between 105 F and 120 F at faucets accessible to clients.
-Secure location for Medications.
-Files are kept in a centralized & locked area in the office.
-Toxins and knives are secured.
-Facility sketch was accurate.
-Non-perishable and perishable food supplies were sufficient.
-Pots, pans, utensils, and kitchen supplies were adequate.
-Furniture items and linen supplies are available.
-Activity supplies were sufficient for client use.
-Emergency information and telephone numbers were posted at facility.
-Fire extinguishers were charged and inspected within the last 12 months.
-First aid supplies, including lighting supplies were available.

Component III orientation was conducted.

This application is ready for submission to the Licensing Program Manager for review and approval of facility license.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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